According to a new paper, just published in JAMA Oncology, the vast majority of Swedish men diagnosed with very low- and low-risk prostate cancer are now being initially managed on active surveillance.

Loeb et al. used data from the National Prostate Cancer Register (NPCR) of Sweden from 2009 through 2014 to conduct an up-to-date, nationwide, population-based assessment of the use of active surveillance for the management of localized prostate cancer in Sweden. And it is important to understand that the NPCR has accumulated data on 98 percent of all prostate cancers diagnosed in Sweden — as well as comprehensive linkages to other, relevant nationwide databases.

So here are the key findings from this most recent study on the uptake of active surveillance by Swedish physicians and their patients (see also this media release issued by the New York University Langone Medical Center):

32,518 Swedish men with a median age of 67 years were diagnosed with favorable-risk prostate cancer between 2009 and 2014.

4,693/32,518 men (14.4 percent) were diagnosed with very low-risk disease (as a subset of the low-risk group of men given below), meaning that they had a clinical stage of T1c, a Gleason score of ≤ 6, a PSA level of < 10 ng/ml, a PSA density < 0.15 ng/ml/cm3, and < 8 mm of cancer in total length spread over ≤ 4 positive biopsy cores.

15,403/32,518 men (47.4 percent) were diagnosed with low-risk disease, defined as clinical stage T1-T2, with a Gleason score of ≤ 6, and a PSA level of < 10 ng/ml.

17,115/32,518 men (52.6 percent) were diagnosed with intermediate-risk disease, defined as clinical stage T1-T2, with a Gleason score of 7, and/or a PSA level of 10-20 ng/ml.

Between 2009 and 2014, the use of active surveillance as a first-line management strategy

Increased from 380/665 men (57.1 percent) in 2009 to 939/1,027 men (91.2 percent) in 2014 for men diagnosed with very low-risk prostate cancer

Increased from 1,159/2,895 men (40.0 percent) in 2009 to 1,951/2,644 men (73.7 percent) in 2014 for men diagnosed with low-risk prostate cancer

Was 561/3,030 (18.5 percent) in 2014 among men diagnosed with intermediate-risk prostate cancer

Simultaneously, the number of men in the very low-risk and lpow-risk groups who chose to simply wait, do no further testing, and postpone therapy unless symptoms develop (watchful waiting) dropped by more than half.

The greatest increases in acceptance of active surveillance occurred from 2011 to 2014,

In 2014 itself, among men aged 50 to 59 years, the use of active surveillance as a first-line management strategy

Was 211/240 (87.9 percent) among men diagnosed with very low-risk prostate cancer

Was 351/518 (67.8 percent) among men diagnosed with low-risk prostate cancer

The authors conclude that:

Active surveillance has become the dominant management for low-risk prostate cancer among men in Sweden, with the highest rates yet reported and almost complete uptake for very low-risk cancer. These data should serve as a benchmark to compare the use of active surveillance for favorable-risk disease around the world.

Quoted in the media release referred to above, Dr. Loeb herself went one step further:

The main conclusion here is that if the majority of men in Sweden have adopted this management strategy for very low- to low-risk prostate cancer, then more American men might choose this option if it were presented to them, …

Our findings should encourage physicians and cancer care professionals in the United States to offer such close supervision and monitoring to their patients with low-risk disease, …

and that if more American men were to opt for active surveillance, this

could go a long way toward reducing the harms of screening by minimizing overtreatment of non-aggressive prostate cancer.

2 Responses

Bottom line: worldwide, no one (less than 0.0001%) dies from Gleason 3 + 3 prostate cancer. In Sweden or in the USA. Nor does Gleason 3 + 3 progress/metastasize into problematic Gleason 4 + 3 = 7 or higher disease. Wake up American physicians. Watch and listen to Dr. Klotz, a pioneer in active surveillance, with 20 years of professional experience.

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